Anthem Blue Cross Application Instructions Page

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Please Note:
Coverage is not available if:

1. Any family member is currently pregnant (whether or not listed on the application) or in the process of adoption.
2. The applicant has not resided in the U.S. for the last six (3) consecutive months.
3. A permanent legal resident of California

Coverage is not guaranteed.  Your application must be approved and accepted in writing by Blue Cross.  Do not cancel existing coverage until you receive written notification by Blue Cross.

Instructions

• For your own protection, you, the applicant, must complete the application.  You are solely responsible for its accuracy and completeness.
• If you, the applicant, do not complete the application, the translator must complete the "Statement of Accountability".
• All information must be stated accurately.
• All questions must be answered in full or the application may be returned to you and may result in a delay in processing.
• For additional information or explanations, attach sheets if necessary.  All attachments must be signed and dated.
• This application must be signed in blue or black ink.
• This application must be received by Blue Cross Medical Underwriting within 45 days from signature date.
• Blue Cross plans are available only in areas where the Blue Cross network exists.  Please see the appropriate provider directory for more details.
• Even if the application is approved, any misstatements or omissions may result in future claims being denied and the plan being voided from the beginning.
• Your insurance will become effective only if this application is approved as applied for, the appropriate premium is enclosed, and other specific conditions are met.
• Please return this application and your check to (Make Check payable to "Blue Cross of California") or complete the Credit Card Authorization section on the back of the application:

Family Elect - Each family member can choose a different medical plan.

• First indicate you are choosing to participate in the program by checking "Yes" for FamilyElect in Section 2.
• Next, go to Section 2.  List the corresponding medical plan code number from Section 2 (i.e. code 7891 for PPO Share 2500 plan).
• To figure your premium, choose the rate appropriate to your benefit choice, age and rating area.
• Add the monthly rates together for all plans and submit one check.
• If you have any questions please call us at (619) 435-6700.

For families, each member can complete their own separate application form or apply through the FamilyElect Programs. For FamilyElect, the client should indicate the RightPlan contact doe for each individual family member in Section 3B, FamilyElect Medical Coverage. Be sure to review all disclosure materials, including information about the terms, conditions, limitations and exclusions of coverage. Click Here to view RightPlan Brochure

Billing Information:

Carefully read the instructions accompanying each billing type on page 7.  Please make sure that your check is attached where indicated on page 7 of this application.

• Monthly Billing (available with Bank Draft Authorization only): Submit the one (1)-month premium, complete the Monthly Bank Draft Authorization and attach a blank check marked "VOID" to this form.
• Bi-monthly billing: Submit the two (2)0month (bi-monthly) premium.
• Quarterly billing: Submit the three (3)-month (quarterly) premium.
• Initial premium payment by credit card and monthly billing by credit card: Complete Section 8A authorizing initial payment for medical and/or dental premium.

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